«CHAPTER 2: THE ASSESSMENT SCHEDULE FOR THE RAI This chapter presents the instructions for the completion of the mandated clinical and Medicare ...»

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CMS’s RAI Version 2.0 CH 2: Using the RAI

CHAPTER 2: THE ASSESSMENT SCHEDULE FOR

THE RAI

This chapter presents the instructions for the completion of the mandated clinical and

Medicare assessments in nursing facilities.

2.1 Introduction to the OBRA Assessment Schedule for the MDS

INTRODUCTION TO THE OBRA ASSESSMENT SCHEDULE

The OBRA regulations have defined a schedule of assessments that will be performed for a nursing facility resident at admission, quarterly, and annually, whenever the resident experiences a significant change in status, and whenever the facility identifies a significant error in a prior assessment. These are known as “OBRA assessments.” MDS assessments are also required for Medicare payment purposes and are discussed in detail in Section 2.6.

When the OBRA and Medicare assessment time frames coincide, one assessment may be used to satisfy both requirements. When combining OBRA and Medicare assessments, the most stringent requirement for MDS completion must be met. It is important for facility staff to fully understand the requirements for both types of assessments in order to avoid unnecessary duplication of effort.

OBRA ASSESSMENTS

When the resident is first admitted to a facility, the RN Assessment Coordinator (RNAC) and the interdisciplinary team will agree on a period known as the observation period for the Admission assessment. The last day of this observation period is the Assessment Reference Date (ARD). This is the end date of the observation period and provides a common reference point for all team members participating in the assessment. In completing sections of the MDS that require observations of a resident over specified time periods such as 7, 14, or 30 days, the ARD is the common endpoint of these “look back” periods. This concept of setting the ARD is used for all assessment types. When completing the MDS, only those items that occurred during the look back period will be captured. In other words, if it did not occur during the look back period, it should not be coded on the MDS.

When all members of the team have completed their portions of the assessment and the assessment is complete, the RN Assessment Coordinator (RNAC) will sign Item R2a and will date Item R2b with the date that R2a was signed. The R2b date is the completion date for all assessment types that do not require RAPs, and is the date used to determine when the next OBRA assessment is to be completed. An OBRA assessment is due no less frequently than every 92 days.

Resident Assessment Protocols (RAPs) are reviewed following the completion of the MDS portion of the RAI for comprehensive assessments in order to identify the resident’s strengths, problems, and needs. This decision-making process is documented on the Resident Assessment Protocol Summary, which is detailed in Chapter 4.

Revised—December 2002

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The timing requirements for a comprehensive assessment apply to both completion of the MDS (R2b) and the completion of the RAPs (VB2). For example, an Admission assessment must be completed within 14 days of admission. This means that both the MDS and the RAPs (R2b and VB2 dates) must be completed by day 14. The MDS Completion Date (R2b) may be earlier than or the same as the RAPs Completion Date (VB2), and neither can be later than day 14.

The comprehensive RAI is considered complete on the date the RN Coordinator indicates completion of the RAPs (VB2). The care plan must be completed by the end of the 7th day following completion of the RAI assessment. In other words, 7 days following the VB2 date.

Assuming the resident does not have any significant changes in status or is not discharged from the facility, the next assessment in the OBRA assessment schedule is the Quarterly assessment. The Quarterly assessment is to be completed within 92 days of the R2b date of the Admission assessment. The OBRA schedule would continue with another Quarterly assessment to be completed within 92 days of the R2b of the previous Quarterly. A third Quarterly is completed within 92 days of the completion (R2b) of the previous Quarterly.

Following the third Quarterly, and within a year of the Admission assessment, an Annual assessment is completed. This is a comprehensive assessment that requires a full MDS with RAPs and care plan review.

However, residents do experience significant changes, are discharged and are readmitted to facilities.

Therefore, OBRA regulations have defined a comprehensive assessment that a facility completes in the event of a significant change in status that includes RAP review and care plan revision. When a resident is discharged from a facility, a Discharge Tracking form may be required. When a resident who was discharged returns to a facility, a Reentry Tracking form may be required. When a resident is readmitted to the hospital and an OBRA-required assessment is due during the resident’s absence, the facility has up to 14 days after the resident’s readmission to complete the assessment. If the assessment that was due during the resident’s absence was the initial Admission assessment, see page 2-4. If a significant change is identified on readmission, the significant change assessment would replace the assessment that was due while the resident was in the hospital. (Error messages will result from the late assessment but can be ignored.) The Significant Change in Status assessment, and the Discharge and Reentry Tracking forms, including their impact on the assessment schedule are discussed in more detail later in this chapter.

A comprehensive assessment is also required when the facility has identified a major error in a previously submitted comprehensive assessment. A Significant Correction of a Prior Full assessment (SCPA) must be completed within 14 days of the identification of the error. A major error is one where the resident’s overall clinical status is not accurately represented on the MDS, has not been addressed in a subsequent assessment, nor addressed in the resident’s care plan. Because this is a comprehensive assessment, completion of the full MDS, RAPs and the RAPs Summary is required.

This page revised August 2003

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The MDS is also completed for the Medicare Prospective Payment System. The Medicare schedule is discussed in detail in Section 2.5

2.2 Required OBRA Assessments for the MDS

ADMISSION ASSESSMENTS

The Admission assessment is a comprehensive assessment for a new resident that must be completed

within 14 calendar days of admission to the facility if:

• this is the resident’s first stay,

• the resident has just returned to the facility after being discharged prior to the completion of the initial assessment, or

• the resident has just returned to the facility after being discharged as return not anticipated.

The 14-day calculation includes weekends. When calculating when the RAI is due, the day of admission is counted as Day “1”. For example, if a resident is admitted at 8:30 a.m. on Wednesday This page revised December 2005, August 2003

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(Day 1), a completed RAI is required by the end of the day Tuesday (Day 14), 13 days after admission. If a resident dies or is discharged within 14 days of admission, then whatever portions of the RAI that have been completed must be maintained in the resident’s discharge record.1 In closing the record, the facility may wish to note why the RAI was not completed.

The interdisciplinary team may start and complete the initial assessment at any time prior to the end of the 14th day. If desired by the facility, the MDS could be completed in entirety on the day of admission. However, this requires the staff to rely on resident and family reporting of information and transfer documentation to a large degree as a source of information on the resident’s status during the time periods used to code each MDS item, as opposed to allowing a period for facility observation. Facilities may find early completion of the MDS and RAPs particularly beneficial for individuals with short lengths of stay, when the assessment and care planning process is often accelerated.

EXAMPLES

Miss A is admitted on Friday, September 1. Staff establish the Assessment Reference Date as September 8, which means that September 8 is the final day of the observation period for all MDS items (i.e., count back 6 days before the ARD to determine the period of observation for 7-day items, count back 13 days before the ARD for 14-day items, and so on). As this is an initial assessment, staff must rely on the resident and family’s verbal history and transfer documentation accompanying Miss A to complete items requiring longer than a 7-day period of observation. Staff completes the MDS by September 12 (note that the Assessment Reference Date (A3a) does not need to be the same as the date RN Assessment Coordinator signed as complete (R2b). Staff takes an additional 2 days to assess the resident using triggered RAPs and to complete all related documentation, which is noted as a date field that accompanies the signature of the RN Coordinator for the RAP assessment process on the RAP Summary form (VB2).

If a resident goes to the hospital and returns during the 14-day assessment period and most of the initial assessment was completed prior to the hospitalization, then the facility may wish to continue with the original assessment, provided the resident did not have a significant change in status. In this case, the Assessment Reference Date remains the same and the Admission comprehensive assessment must be completed by day 14 counting from the original date of admission. Otherwise the assessment should be reinitiated with a new Assessment Reference Date and completed within 14 days after readmission from the hospital. The portion of the resident’s assessment that was previously completed should be stored on the resident’s record with a notation that the assessment was reinitiated because the resident was hospitalized.

The RAI is considered part of the resident’s clinical record and is treated as such by the RAI Utilization Guidelines, e.g., portions of the RAI that are “started” must be saved.

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• The above chart summarizes how to count the days for various points within the admission assessment. As stated previously, the date of admission is Day 1 for determining when the assessment must be completed and for setting the Assessment Reference Date. Once the ARD has been established, then the ARD is day 1 whenever counting back for those items observed over a specific time period.

• Both the MDS Completion Date (R2b) and RAPs Completion Date (VB2) must be dated within 14 days of admission. R2b must always be earlier than or the same as VB2. If R2b is dated prior to day 14, VB2 may or may not be the same day, but can be no later than day 14.

• Care Plan Completion Date (VB4) must be dated by the end of the 7th calendar day following VB2 (VB2 + 7 days) and can be no later than day 21.

• Electronic submission is due within 31 days following VB4 (VB4 + 31 days).

ANNUAL REASSESSMENTS

The annual comprehensive assessment must be completed within 366 days of the completion date at VB2 of the most recent comprehensive assessment (could be the Admission assessment, an Annual assessment, a Significant Change in Status assessment or a Significant Correction of a Prior Full assessment). If a significant change reassessment is completed in the interim, the clock “restarts,” and the Annual assessment would be due within 366 days of the significant change reassessment.

Routinely scheduled RAI assessments may be scheduled early if a facility wants to stagger due dates for assessments.

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